How should isolated redness at the medial canthus be treated?

Treatment of Isolated Redness at the Medial Canthus

Start with preservative-free ocular lubricants 2-4 times daily immediately, and urgently assess whether this is medication-related (particularly dupilumab/Dupixent) or represents another etiology requiring different management. 1

Immediate Assessment: Medication-Related vs. Other Causes

If Patient is on Dupixent (Dupilumab)

Screen immediately for red flag symptoms requiring emergency ophthalmology referral within 24 hours: 1

• Visual acuity loss (even self-assessed)
• Eye pain
• Photophobia (light sensitivity)
• Visible corneal damage or ulceration 2, 1

Note: Unilateral symptoms are unlikely to be dupilumab-related and suggest alternative pathology requiring standard ophthalmology pathways. 2, 1

First-Line Treatment for Dupilumab-Related Medial Canthal Redness

Initiate preservative-free ocular lubricants 2-4 times daily immediately, even if redness appears primarily facial, as ocular involvement is common (6-26% of patients). 2, 1

Treatment Escalation Algorithm for Dupilumab-Related Cases

For mild redness (trace conjunctival injection, minimal symptoms): 2

• Continue preservative-free lubricants 2-4 times daily
• Reassess in 2-4 weeks
• Refer to ophthalmology within 4 weeks if no improvement 2

For moderate redness (mild-to-moderate conjunctival injection with symptoms): 2, 1

• Preservative-free lubricants 2-4 times daily PLUS
• Topical antihistamine eyedrops (olopatadine) twice daily 2
• Refer to ophthalmology within 4 weeks 2

For severe redness (severe conjunctival injection regardless of symptoms): 2, 1

• Continue preservative-free lubricants 2-4 times daily
• Add tacrolimus 0.1% ointment once daily to lid margins
• Urgent ophthalmology referral within 24 hours to 4 weeks based on clinical judgment 2, 1
• For patients aged 7-17 years, seek ophthalmology advice before starting tacrolimus 2

If NOT Medication-Related

Consider Alternative Diagnoses

Assess for infectious, inflammatory, or structural causes: 2

• Blepharitis: Treat with warm compresses 5-10 minutes once or twice daily plus eyelid hygiene with diluted baby shampoo 3
• Conjunctivitis: Determine if bacterial, viral, or allergic based on discharge character and bilaterality 2
• Contact lens-related complications in younger patients 4

For isolated medial canthal redness without systemic medication exposure: 3

• Warm compresses 5-10 minutes, 1-2 times daily 3
• Gentle eyelid cleansing with hypochlorous acid (0.01%) eyelid cleaners for antimicrobial effects 3
• Preservative-free artificial tears for associated dry eye symptoms 3

Topical Options for Facial Redness Component

If redness extends to facial skin around medial canthus: 1

• Topical oxymetazoline 0.05% applied daily to reduce redness appearance 1
• Topical brimonidine tartrate 0.33% applied daily (FDA-approved for rosacea-related redness) 1
• Short-term hydrocortisone 1% cream to facial skin only (NOT in eyes) if inflammation is severe 1

Critical Clinical Pitfalls to Avoid

Do not delay ophthalmology referral for red flag symptoms—visual outcomes depend on prompt intervention. 1

Avoid alcohol-containing preparations on facial skin, as they worsen dryness and barrier function. 1

Do not use topical corticosteroids for more than 6 weeks without ophthalmology monitoring and corticosteroid-sparing therapy. 1

Bilateral involvement is typical for dupilumab-related issues; unilateral presentation suggests alternative diagnosis. 2, 1

Reassurance for Patients on Dupixent

Only 4.2% of patients discontinue Dupixent due to ocular complications—most cases are manageable while continuing therapy. 1